Medicaid Saved Obamacare, and Single-Payer Universal Health Insurance May Be Back on the Agenda Sooner Than You Think

A lot of the reporting on Trump’s epic failure on the attempted repeal of Obamacare has focused on the Freedom Caucus, a group of libertarian-minded representatives for whom the administration’s bill did not go far enough in obliterating the gains from the Obama administration’s expansion of health care coverage.

But the defeat of Trump’s American Health Care Act (AHCA) may have had more to do with the pressure — including grassroots organizing — and risks faced by many Republican representatives who feared taking away insurance that most voters want. And one cannot assume that all members of the Freedom Caucus acted out of ideological concerns; they too have constituents that need health care.

Much of this is explained, with examples and some history, in an excellent article from The New York Times. And there are broader implications for the way forward.

About 11 million of the approximately 20 million people who gained health insurance under Obamacare did so under its provision for expansion of Medicaid, the joint Federal/state program that provides health insurance for low-income Americans. The expansion included people with income up to 138 percent of the poverty line.

The Times summed up how far-reaching Medicaid had become, now enrolling 21 percent of the population — more than Medicare (the program of public health insurance for Americans over 64):

Medicaid now provides medical care to four out of 10 American children. It covers the costs of nearly half of all births in the United States. It pays for the care of two-thirds of people in nursing homes. And it provides for 10 million children and adults with physical or mental disabilities […] almost two-thirds of Americans in a poll by the Kaiser Family Foundation said they were either covered by Medicaid or had a family member or friend who was.

Medicaid is not a universal entitlement, but it is an entitlement that now affects tens of millions of people who are not poor. This provides it with some considerable political protection. The only major entitlement that was taken away from us was Aid to Families with Dependent Children (AFDC), which was undone by the Clinton administration in 1996. It was vulnerable because it served only poor people; sadly, since its repeal, there has been a large increase in the number of people living in extreme poverty.

The Republicans thought they could similarly decimate a program that was designed for low-income people, but this one now has too big of a base. The Congressional Budget Office estimated that the Republican bill would have reduced the number of people receiving Medicaid by 14 million over 10 years. And a lot more people would be affected than these numbers indicate: millions go in and out of enrollment, and millions of people have family members in nursing homes or who are disabled, that they could not afford to take care of without Medicaid.

In the area of health insurance, as in retirement income, universal social insurance is clearly the way to go. Social Security has become the “third rail” of American politics — nobody can touch it — because it works and because most Americans believe in the basic values that it represents: that people have a right to a secure retirement, and it is reasonable to tax current income in order to provide for the future retirement security of everyone. Attempts to partially privatize it in the 1990s and in 2005 were defeated.

Obamacare was a step toward universal health care, most importantly with the expansion of Medicaid. Obama could not get universal, single payer health care but the system that was created suffers from a number of weaknesses, including adverse selection in the private insurance exchanges that it created (i.e. not enough healthy people in the insurance pool). Trump has announced that he would await its impending “implosion” and “explosion,” and has plenty of administrative power to sabotage the current system. Other Republicans have declared they will find a way to repeal it.

In the wake of the Republican defeat, Bernie Sanders announced that he would introduce a bill for universal, single payer, health insurance — i.e. Medicare for everyone. With the Republicans controlling Congress and the presidency, this may seem a symbolic or even quixotic gesture. But there are some sensible reasons to relaunch this effort right now. Even if the Democrats were in charge, it would take a few years to make any significant progress toward this goal. If present trends continue, the Trump presidency will be an unmitigated disaster, and we will be facing a very different political alignment four years from now.

Some polls have shown majorities in favor of single payer health care. In the last election cycle we also went rather quickly from a widely believed politician-and-media-backed falsehood that Social Security was in serious financial trouble, to even Hillary Clinton saying that benefits needed to be expanded, not cut. That is the direction that the country is going, with Bernie Sanders, despite losing the Democratic presidential primary, being one of the most popular politicians in the country; and Trump in the doghouse with 37 percent approval.

The economic case for universal, single-payer health care has long been irrefutable, and the fact that we pay twice as much per person for health care as the average high-income country and have worse health outcomes is a constant reminder. Of course there is the political power of the private insurance and pharmaceutical companies, and other special interests, and that has stood in the way. But look at what just happened to the Trans-Pacific Partnership agreement. That was legislation that the most powerful interests in the country — not only corporations but also the “national security state” wanted so badly they just couldn’t stop lying about it. And yet the public interest prevailed.

That was a result of 20 years of organizational and educational work. Hopefully it won’t take us that long to get to real universal health care. But there is no time to waste.